We all lose hairs every day, but when does it signify a problem? When should you worry about your child losing too much hair?

A lot of parents ask about hair loss in their kids. When is it normal and when should they worry? I’ve had a hard time finding reputable online resources for parents over the years.

What I do see reproduced on many sites (mostly hair clinic sites, nothing I would rely on for information) is that both Fall and Spring are a time of normal hair thinning. Studies link hair growth to sun exposure and melatonin levels. I am definitely not a hair expert, but wanted you to know some warning signs of abnormal hair loss and when it is safe to wait it out.

Notice the hair loss pattern.

Most of us lose 50-100 head hairs a day. Long hair is obviously more noticeable when lost, since it plugs shower drains, accumulates on brushes, and is seen on our clothing.

Simply seeing hair being lost is not a concern.

Hair loss causes

Some causes of hair loss are easily identified. Others are harder to identify because associated symptoms are vague and not always noted to be associated with hair loss. If you are concerned, make an appointment to discuss it with your child’s doctor. Since this can be a chronic issue, it is not ideally handled at an urgent care or walk in clinic. If indicated by the findings of their exam, your child’s doctor may refer to a dermatologist, endocrinologist, or other specialist, but many of these can be managed by your pediatrician.

Traction: Braids or other hair styles that pull the hair shafts (as in picture above) can cause hair loss in a pattern easily identified by the hair style. Treatment is simple: stop styling the hair with traction. If continued, damage to the hair follicles might make regrowth impossible.

Babies often have hair breakage from friction on the back of their head. It usually develops the first few months of life. When they start sitting up most of the day and sleeping on their tummies it regrows. (Note: Do NOT put your baby to sleep on his tummy to prevent this. Tummy sleeping is associated with SIDS.)

Trichotillomania (or hair pulling disorder) is the compulsive urge to pull out (even sometimes eat) hair. It can be seen in infants and toddlers, but peaks in young school aged kids. Treatment can be difficult and involves behavioral therapy. There is some encouraging research into N-acetylcysteine (NAC) treating trichotillomania and other behaviors.

Ringworm of the scalp is a fungal infection that can cause hair to break, leaving the base of the hair in the scalp. The skin can appear red and/or scaly. It can be secondarily infected with bacteria, causing swelling, pain, and drainage. After the diagnosis is confirmed, an oral medication is needed.

Malnutrition can cause thinning of the hair, growth problems, behavior problems, muscle wasting, and abdominal swelling. Too little iron and/or protein in the diet can lead to hair loss. Biotin, zinc, and B12 deficiency are specific associations. In this country malnutrition is very uncommon. Treatment involves improving nutrition and addressing any underlying condition causing the malnutrition.

Too much Vitamin A has been linked to hair loss. If your child takes supplements, be sure to let your doctor know when you are discussing hair loss.

Hypothyroidism (low thyroid levels) has many symptoms, including thinning of hair. Not all need to be present, and some symptoms can be there without hypothyroidism because they are vague and common issues. Hair may become brittle and break off more easily. Hypothyroidism can cause kids to feel tired and not have much energy. Constipation is a frequent complaint. Heartbeats might slow and kids may feel cold when others are comfortable. Skin is often dry. Kids can slow their growth and may become overweight. Blood tests can help identify hypothyroidism and thyroid hormone replacement can treat it.

Uncontrolled diabetes can affect hair growth and loss. Working with an endocrine specialist is important to get diabetes under control.

Polycystic ovarian syndrome (PCOS) can affect hair thickness. Girls with PCOS can have excessive hair growth on their body but male pattern hair loss on the head, acne, obesity, diabetes, heart disease, high blood pressure, and abnormal menstrual cycles. Blood tests along with a history and physical can help identify PCOS.

Medications can cause hair loss. The most commonly known type are chemotherapy drugs, but also some acne medicines, anabolic steroids and lithium can cause hair loss. If hair loss is a concern, be sure your doctor knows all the medicines and supplements you give your child.

Hair treatments: chemical treatments, such as coloring, straightening, bleaching and curling can lead to hair loss. Heat from a hair dryer, curler, or flat iron can break hairs. Even combing wet hair leads to more breakage because wet hair is more elastic. Limiting these treatments can allow hair to re-grow.

Severe stress, including that from infection or surgery, can lead to sudden hair loss. Because hair grows slowly, this is seen many weeks to months after the event. It will regrow, usually within 6 -12 months.

As you can see, there are many causes of hair loss and the treatment for each varies based on the cause. If you feel like your child has balding areas, generally thinning hair, or other issues with hair loss, please call to schedule a visit to discuss the concerns with your primary care physician.

Summer’s in full swing. I love to see neighborhood kids out playing. We don’t see that enough these days. I want kids to have fun outdoors for fresh air and exercise. Bike safety should be taught early on and encouraged every time people young and old are on bikes.

Twice already this summer kids have told me about friends who had ugly accidents due to wearing flip flops or sandals on a bike. My patients hear the message to cover their heads with a helmet and feet with proper shoes before bikes and scooters. These kids listened but not their friends.

My favorite bike safety tips are in this easy to read and share infographic.

What measles vaccines are available?

There are two types of measles vaccines in the United States: MMR and MMRV.

There is no longer a separate measles vaccine available in the US.

MMR

The MMR includes protection against measles, mumps, and rubella. This vaccine can be used in infants 6 months and older and is the only vaccine approved over 13 years of age for those who need to catch up on vaccines.

MMRV

In addition to measles, mumps, and rubella, the MMRV has protection against varicella (chicken pox). The MMRV can be used from 12 months through 12 years of age (until the 13th birthday).

Using the MMRV vaccine has the benefit of one fewer injection, but there are some downsides.

It cannot be used as an early dose of measles protection prior to 12 months of age.

The MMRV should not be used in those 13 years and older.

The MMRV has a higher risk of fever within 42 days after vaccination compared to the MMR and Varicella vaccines being given in separate injections, even when they’re given on the same date in children 12-24 months of age. There is less data on children 24-47 months of age, but it is likely that they also have this increased risk.

The MMRV has a higher risk of febrile seizures from 5-12 days after vaccination compared to the MMR + Varicella being given in separate injections, even if given on the same date.

What is the typical age of vaccination?

One of the measles vaccines is recommended routinely at 12-15 months and then again at 4-6 years.

Either the MMR or the MMRV can be used at these standard times.

If the MMR is used, a separate varicella vaccine can be used at the same time or at a different time.

Can the 2nd dose be given early?

Yes. An early 2nd dose does count as the second dose as long as it is separated by at least 28 days from other live virus vaccines.

Early second doses do count toward the required two doses after the first birthday. There is no minimum age for the second dose, as long as both doses are after the 1st birthday and a month apart.

What does the booster dose do?

Contrary to common belief, the MMR/MMRV second dose is not a booster to increase the immunity of the first dose.

About 93% of people respond to their first measles vaccine and are protected against the measles. They are protected and wouldn’t need a booster, but we can’t easily tell if any individual person is immune after the first dose. It is also possible that a person is immune to some of the MMR/MMRV components but not to all of the components, so another dose is needed for protection to be more reliable.

The second vaccine helps more people convert to being immune. After the second dose, 97% of people are immune to measles.

There are some people (3%) who are not immune despite two doses, which is why we sometimes hear of a vaccinated person still getting the disease.

Herd immunity is one reason why it is important for everyone in a community who is eligible to get the vaccine to be immunized. By immunizing the community, we can protect those in the community who are not able to be vaccinated due to young age or medical condition and those who are vaccine non-responders.

High risk situations: outbreaks and travel

It is recommended to receive an MMR (or MMRV if age indicated) if there is a local outbreak and the health department recommends an early vaccine or if an infant 6-12 months of age will be traveling to an area of increased risk.

Infants and children in high risk areas can get the second dose as early as 4 weeks after the first.

Either of the measles vaccines can be used as long as they are indicated for the age of the person being vaccinated.

More about early doses

MMR can be given to infants at least 6 months of age if they are considered high risk due to travel or outbreaks.

It is not recommended for all babies to get an early vaccine at this point.

Local health departments help to advise whether or not local conditions warrant early vaccination.

International travelers should be vaccinated against measles after 6 months of age due to the higher risk of exposure during travel.

Why not give to babies under 6 months?

Under 6 months of age an infant is considered protected from his or her mother’s antibodies. These antibodies leave the baby between 6 and 12 months after birth.

The antibodies prevent the vaccine from properly working, which is why we generally start the vaccine after the first birthday, when the antibodies have likely gone away.

Does an early dose count?

Any measles vaccine dose given before the first birthday does not count toward the two doses required after 12 months of age, but might help protect against exposure if the immunity from the mother is waning.

As mentioned above, an early 2nd dose does count as long as the first dose is after the 1st birthday and the second dose is at least 28 days later.

Is it safe to give the MMR before 12 months?

It is safe for a child to get extra doses of the vaccine if needed for increased risk of exposure between 6 and 12 months.

As discussed above, it is not because of safety that it is not routinely given earlier. It may not be effective at this age if the baby still has maternal immunity.

What’s the deal with live virus vaccines?

All live virus vaccines must be given either on the same date or a month apart. If they are given too close together on different dates they are less effective and the second one given does not count.

Other types of vaccines do not have this restriction, only live virus vaccines.

Examples of live virus vaccines include:

Oral typhoid (not on the routine vaccine schedule, but recommended for international travel)

BCG (a vaccine against tuberculosis that is used in some countries, but not the US)

Oral polio (a vaccine no longer used in the US, but still in use in other countries)

Yellow fever (not on the routine vaccine schedule, but required prior to visiting some countries)

Zoster (a vaccine for older adults, not children)

For example…

If your child has FluMist (the nasal flu vaccine) on October 1st, if he or she gets the MMR or MMRV on October 15th, the MMR/MMRV won’t count.

This is becoming more difficult to track as pharmacies, work places, and other clinics offer vaccines. I can think of one instance where a parent had a child get a nasal flu vaccine a couple of weeks before the other parent brought the child in for kindergarten shots. The 2nd parent was not aware of the flu vaccine, so the live virus vaccines given at the routine well visit had to be repeated a month later. The child was not happy!

Always get documentation of the vaccines your child gets and be sure if it’s not done at your child’s primary care office that they get a copy! If you’re transferring to a new physician, request a transfer of records in writing before your first visit to your new medical home so they have what they need to best care for your family!

Tuberculosis testing with PPD

Although this is not a live virus vaccine, tuberculosis testing can also be affected by live virus vaccines.

A false negative skin test can occur if any live vaccine is given during the month BEFORE the TB skin test is done.

If MMR vaccine is given, you should wait at least 4 weeks before doing the TB skin test unless it is given on the same date.

All vaccines, live or inactivated, can be given on the same day or at any time AFTER a TB skin test is done.

What if someone who hasn’t been vaccinated is exposed to measles?

Unvaccinated people who are exposed to measles can be given post-exposure prophylaxis unless they have a vaccine contraindication.

If the MMR vaccine is given within 72 hours of initial measles exposure it may provide some protection or lead to a less severe infection.

Immunoglobulin (IG) can be given within 6 days of exposure to provide some protection.

If you think you’ve been exposed, contact your physician and/or the local health department.

Who shouldn’t be vaccinated?

The long list of medical contraindications to vaccines that some promote is not valid. There are very few contraindications to getting the MMR vaccine. These include:

Age less than 6 months of age

Anyone who has had a severe allergic reaction (anaphylaxis) after a previous dose or to a vaccine component or neomycin

Those with a known severe immunodeficiency (chemotherapy, congenital immunodeficiency, long-term immunosuppressive therapy, and some with human immunodeficiency virus [HIV] infection)

Pregnant women

Some conditions have precautions, but not true contraindications, to the MMR vaccine. The risks and benefits of vaccination should be discussed if a person has the following:

Moderate or severe acute illness

Tuberculosis testing (see separate section above)

Antibody-containing blood products within the previous 11 months

Those who have received a live virus vaccine in the previous 4 weeks

Seizure history

What about adults?

People born before 1957 are presumed to be immune to measles because they lived through several measles epidemics before the vaccine became available.

It is not considered necessary to check titers for these adults unless they are in a high risk group, such as healthcare providers. If their titers do not show immunity, they should be vaccinated according to current recommendations.

Adults born after 1957 should have documentation of two measles vaccines or the disease. Before 1980 it was only recommended to have one vaccine, so some adults may require another dose.

If documentation is not available, titers can be done to see if you’re immune or need a vaccine. Some may choose to simply get an MMR. Talk to your doctor.

Checking titers

Titers can show if people are at risk, but are not recommended routinely. Because of the overall high level of protection (97%), the cost-benefit ratio of testing titers routinely is not in favor of testing.

Certain persons, such as healthcare providers, may have to show immunity or get additional vaccine doses.

In summary

Two doses of one of the measles vaccines available is recommended for everyone after their first birthday. A dose can be given between 6 and 12 months if there is high risk but it does not count toward those two.

The MMR vaccine can be used in any person over 6 months of age if they are needing a measles vaccine, as long as they have not received another live virus vaccine in the previous 28 days.

The MMRV vaccine can be used between 12 months and 13 years of age. There is a higher risk of fever and febrile seizures with this vaccine compared to the MMR + Varicella vaccines given separately (even on the same date).

The first measles vaccine provides protection 93% of the time. The second dose increases the protection to 97% of people.

It is very important that where you are getting your vaccines has access to previous vaccines given, especially if you are getting any live virus vaccines. Keep a copy of all your family member’s vaccines available at all times.

If you are changing primary care physicians for any reason, have your records transferred prior to your first visit. This must be done in writing, but your doctor must provide these. The cost of these records will be determined by the hospital or clinic and state laws.

Always keep records of your family’s vaccine records easily available. You will need these for school entry, many camps, some volunteer or work positions, and more.

Getting one of the measles vaccines is not the only type of vaccine to get. We’re seeing outbreaks of measles currently, but any of the vaccine preventable diseases can make a come back if given the opportunity.

Why is everyone so worked up about the measles showing up all around the country? Is it really a big deal?

Measles is a big deal. If you understand that, you can stop reading right now. If you’re not sure why it’s so important that we vaccinate against this disease, read on. If you’re worried about the vaccine and haven’t protected your children with it, you need to learn about the disease.

Measles is highly contagious.

But it’s also preventable.

If all eligible persons are vaccinated, we can protect those who can’t be vaccinated due to young age or medical condition. This herd immunity is very important to our communities. Sadly, our herd is not protective at this point. Too many are not vaccinating due to unwarranted fears. This leaves too many vulnerable to disease, which allows infection to spread rapidly.

There are a very limited number of conditions that are true medical exemptions, but if herd immunity is high enough we can keep measles from spreading. Using false exemptions drops that herd immunity rate, leading to outbreaks like we’re seeing now.

We’ve been getting a lot of questions about the vaccine and the risks of the disease, so here’s a quick run down of the risks of a measles infection. I’ll cover the vaccines in the next post.

Why worry?

Measles is highly contagious and can be deadly.

Subacute sclerosing panencephalitis (SSPE) is a rare form of chronic progressive brain inflammation caused by measles virus. It can show up many years after someone is presumed to be healed from the disease, much like shingles can affect a person years after chicken pox disease.

For every 1,000 reported measles cases in the US, approximately 1 case of encephalitis (brain inflammation) and 2-3 deaths is found. The risk for death is greater for infants, young children, and adults than for older children and adolescents.

How contagious is measles?

Measles can be spread through the air of a room 2 hours after an infected person leaves. The rash doesn’t usually appear until approximately 14 days after exposure, 2 to 4 days after the fever begins.

A person is contagious 4 days before the rash starts, so can unknowingly spread the infection for days. They remain contagious for another 4 days after the rash starts.

Over 90% of susceptible people who are exposed will get sick.

Are you willing to put your kids at risk by delaying the vaccine knowing the risks of natural infection?

What vaccines are available?

There are two types of measles vaccines in the United States: MMR and MMRV.

Lawn mowers send many kids and adults to the ER every year. Learn to use them safely with the tips below.

As the winter months (finally) end and the weather warms up, we need to get our lawns in order again. I haven’t written about lawn mower safety in a long time, but as I drive around my neighborhood I’m reminded just how many people don’t realize the dangers.

We need to respect lawn mowers and use them safely.

In 2016, more than 86,000 adults and 4,500 children in the U.S. were treated in emergency departments for injuries related to lawn mowers according to the U.S. Consumer Product Safety Commission. Riding mowers lead to the most injuries, but even walk behind mowers are dangerous.

People can suffer minor and serious cuts, burns, broken bones, eye injuries, loss of limbs, and death. A lawn mower can eject a rock, piece of metal, or wood up to 100 miles per hour, leading to injuries of people in the yard but not near the mower.

Safety Tips

Only use a mower that has protection over hot and sharp parts. Never remove these protective coverings.

Teach kids to never touch a lawn mower. Many are burned by touching a hot mower, even when it is off.

Add fuel only to mowers when they are cool and off.

Never operate a mower when under the influence of alcohol or drugs that impair your level of alertness.

Never leave a running mower unattended. Turn it off before walking away.

Wear protective gloves, goggles, sturdy shoes, and long pants when you use lawn mowers. Never mow barefoot or in sandals.

No one under 16 years should ride on or operate a riding mower.

Riding mowers should have the reverse switch behind the driver, forcing the driver to look behind when placing the machine in reverse.

Push mowers should be used only by people over 12 years of age.

Push mowers should have a control that stops forward motion when the handle is released.

If children must be in the yard during mowing, they should remain at least 20 feet away at all times. Ideally children should not be allowed in the yard when the grass is being cut due to the possibility of flying debris.

Remove stones, toys, and debris from the lawn before mowing to prevent injuries from flying objects.

Mow across slopes with a push mower to avoid pulling the mower over your feet if you happen to slip.

Mow up and down slopes with a riding mower to prevent the mower from tipping over.

Do not cut wet grass.

Use hearing protection. Do not listen to music through your ear buds. The high volume required during mowing is harmful to your hearing.

Do not talk on your phone when mowing. It is a distraction that can lead to accidents.

A little planning and preparation can help everyone in your group stay healthy while traveling. Some preventative treatments take up to 6 months to complete, so talk to your doctor early!

When families are able to travel, it can be a wonderful time of exploration and bonding. Don’t let illness get in the way. Many locations have diseases that you don’t typically see in your home town. Take a little bit of time to learn what you need to do to prepare for your vacation. Insurance doesn’t usually cover travel medicine, so be sure to consider these extra costs when planning a trip.

Keep track of everything

It is a great idea to take pictures of everyone each morning in case someone gets separated from the group. Not only will you have a current picture for authorities to see what they look like, but you will also know what they were wearing at the time they were lost.

Take pictures of your passport, vaccine record, medicines, and other important items to use if the originals are lost. Store the images so you have access to them from any computer in addition to your phone in case your phone is lost.

Have everyone, including young children, carry a form of identification that includes emergency contact information.

Create a medical history form that includes the following information for every member of your travel group. Save a copy so you can easily find it on any computer in case of emergency.

your name, address, and phone number

emergency contact name(s) and phone number(s)

immunization record

your doctor’s name, address, and office and emergency phone numbers

the name, address, and phone number of your health insurance carrier, including your policy number

a list of any known health problems or recent illnesses

a copy of current medications and supplements you are taking and pharmacy name and phone number

a list of allergies to medications, food, insects, and animals

a prescription for glasses or contact lenses

Prepare everyone for local specs

Learn what the local healthcare options are if someone in your travel group gets sick or injured. For several tips, see this travel information from the CDC.

Find out how you can use your phone overseas. Be sure to bring a charger that will work with local electrical outlets.

If you’re traveling with young children, plan ahead for where they’ll sleep. Infants will need a safe place of their own with a firm surface. Everyone will need time to adjust to new time zones.

Vehicle safety risks vary around the world. Know local travel options and risks. Only use authorized forms of public transportation. For general information, see this International Road Safety page. Learn local laws prior to traveling.

Be sure to talk with your teens about drug and alcohol safety prior to travel. Many countries have laws that vary significantly from the United States, and some teens will be tempted to take advantage of the legal nature of a drug or alcohol.

Remind everyone to stay in groups and to not venture out alone.

Dress appropriately for the area. Some clothing common in the United States is inappropriate in other parts of the world. Americans are also at risk of getting robbed, so do not wear things that will make others presume you are a good target.

Wear sunscreen! It doesn’t matter if you’re on the beach or on the slopes, you need to wear sunscreen every time you’re outside. Don’t ruin a vacation with a sunburn. For sunscreen tips, see Sun and Water Safety.

Prevent bug bites

Mosquitos, ticks and other bugs not only cause itchy rashes but they can carry diseases. Using insect repellant properly can help to prevent getting bit.

Use insect repellent with at least 20% DEET to protect against mosquito and tick bites. Follow package directions and reapply as directed. Do not use combination bug sprays with sunscreen. They should be applied separately.

Wear long sleeves and pants. Consider treating your clothes with permethrin and tucking your pants into your socks. Sleep in areas that are screened against bugs.

Vaccines

Extra vaccines may be needed when you travel, especially in infants who are too young to get a measles vaccine on our usual schedule and adults who have not gotten vaccines that are now on the regular schedule.

Before you travel you can look at destination-specific advice on the CDC’s Destination page.

MMR

The news routinely reports outbreaks of measles these days. Many of the US outbreaks are related to an unvaccinated person returning from abroad. The MMR protects against measles, mumps, and rubella.

While our standard vaccine schedule does not recommend the MMR until 12 months of age, the vaccine can be used in infants as young as 6 months. It is considered safe to use in infants, but we don’t know when their immunity from their mother goes down. If the maternal immunity is still active the vaccine won’t work. This immunity typically falls between 6 and 12 months. After 12 months the vaccine is more likely to be effective, so when the risk is lower, it is recommended to wait until that age for the vaccine.

Between 6 and 12 months of age the MMR is recommended for infants considered high risk for being exposed to measles. This is because if their immunity has fallen, we don’t want them to be unprotected. International travel is considered to be high risk. If your baby’s maternal immunity is still high, the vaccine won’t provide protection, but he or she is still protected until that maternal immunity falls.

Because we don’t trust that the vaccine is effective before a year of age, babies who get an early MMR will still need two after their first birthday.

Talk to your baby’s pediatrician about getting the MMR if your child is over 6 months of age. Ideally it will be given at least 2 weeks prior to travel to give the body time to develop immunity.

Hepatitis

Both hepatitis A and hepatitis B vaccines are now on the routine schedule for children in the US, but many adults did not get these vaccines as children. These vaccines are recommended for travel to many locations. Verify if your family has had both hepatitis A and hepatitis B vaccines before you travel.

It is recommended that infants start hepatitis B vaccines at birth. The series is completed at 6-9 months of age. There are catch up schedules for those who haven’t completed the series on time.

Children do not get the hepatitis A vaccine until 12 months of age. If they have not yet started the series and they are over a year, they can start at any time. The booster is given 6-12 months later.

It takes at least 6 months to complete each of these series, so plan early!

Typhoid

Typhoid is not a vaccine routinely given in the US but it is recommended for travel to many parts of the world. There are two main types of typhoid vaccine, injectable and oral.

Children 2 years and older can get an injectable typhoid vaccine, ideally at least 2 weeks prior to travel. It is only one dose and lasts 2 years.

The oral vaccine is only for people 5 years and older. It is given in 4 doses over a week’s time and should be completed at least a week prior to travel. It must be given on an empty stomach (1 hour before eating and 2 hours after eating). Antibiotic treatment can make this vaccine ineffective, so discuss any current medicine you are taking with your doctor. The oral vaccine lasts 5 years.

Neither vaccine is 100 % effective so even immunized people must be careful what they eat and drink in areas of risk.

Meningitis

Meningococcal disease can refer to any illness that is caused by the type of bacteria called Neisseria meningitidis. Within this family, there are several serotypes, such as A, B, C, W, X, and Y. This bacteria causes serious illness and often death, even in the United States.

In the US there is a vaccine against meningitis types A, C, W, and Y recommended at 11 and 16 years of age but it can be given as young as 9 months of age. MenACWY-CRM is approved for children 2 months and older.

There is a vaccine for meningitis B prevention recommended for high risks groups in the US but is not specifically recommended for travel.

Meningitis vaccines should be given at least 7-10 days prior to potential exposure.

Travelers to the meningitis belt in Africa or the Hajj pilgrimage in Saudi Arabia are considered high risk and should be vaccinated. Serogroup A predominates in the meningitis belt, although serogroups C, X, and W are also found. There is no vaccine against meningitis X, but if one gets the standard one that protects against ACWY, they will be protected against the majority of exposures. Boosters for people traveling to these areas are recommended every 5 years.

Yellow Fever

Yellow fever is a mosquito-borne infection that is found in sub-Saharan Africa and tropical South America. There is no treatment for the illness, but there is a vaccine to help prevent infection. Some areas of the world require vaccination against yellow fever prior to admittance. Yellow fever vaccine is recommended for people over 9 months who are traveling to or living in areas with risk for YFV transmission in South America and Africa.

Most physician offices do not offer this vaccine. A special license is required to be able to provide it. Check with your local health department or a travel clinic in your area. This vaccine should be given at least 10 days prior to travel.

Influenza

Remember that influenza hits various parts of the world at different times of the year. The southern hemisphere tends to finish their flu season just as ours is starting. Check to see when it’s flu season and vaccinate as needed.

Medications for your trip

Aside from bringing your routine prescription medications and over the counter medicines in their original prescription container, there are some medications that are recommended for traveling to various parts of the world.

Malaria

Malaria transmission occurs in large areas of Africa, Latin America, parts of the Caribbean, Asia (including South Asia, Southeast Asia, and the Middle East), Eastern Europe, and the South Pacific. Depending on the level of risk (location, time of year, availability of air conditioning, etc) no specific interventions, mosquito avoidance measures only, or mosquito avoidance measures plus prescription medication for prophylaxis might be recommended.

Prevention medications might be recommended, depending on when and where you will be traveling. The medicines must begin before travel starts, continue during the duration of the travel, and continue once you return home. There is a lot of resistance to various drugs, so area resistance patterns will need to be evaluated before choosing a medication. Review the area-specific travel recommendations with your doctor.

Anti-diarrhea medicines

I am commonly asked to prescribe antibiotics to prevent traveler’s diarrhea. This is discouraged due to growing bacterial resistance to antibiotics. It is best to prevent by avoiding local water, choosing foods wisely, using proper handwashing techniques, and considering bismuth subsalicylate or probiotic use.

Traveler’s diarrhea is often from bacteria, but it can also be from a viral source. Maintaining hydration with clean water with electrolytes is the most important treatment. Many cases of traveler’s diarrhea do not require antibiotics. See details of treatment recommendations in the Yellow Book.

After you return…

If you’ve been in an area of the world that has increased risk for tuberculosis (TB) or if you have suspected exposure to TB, testing for exposure is recommended.

Tuberculosis occurs worldwide, but travelers who go to most countries in Latin America, the Caribbean, Africa, Asia, Eastern Europe, and Russia are at greatest risk.

Travelers should avoid exposure to TB in crowded and enclosed environments. We should all avoid eating or drinking unpasteurized dairy products.

The vaccine against TB (bacillus Calmette-Guérin (BCG) vaccine) is given at birth in most developing countries but has variable effectiveness and is not routinely recommended for use in the United States. Those who receive BCG vaccination must still follow all recommended TB infection control precautions and participate in post-travel testing for TB exposure.

It is recommended to test for exposure in healthy appearing people after travel. It is possible to have a positive test but no symptoms. This is called latent disease. One can remain in this stage for decades without any symptoms. If TB remains untreated in the body, it may activate at any time. Typically this happens when the body’s immune system is compromised, as with old age or another illness. Appropriately treating the TB before it causes active disease is beneficial for the long term.

Drowning is one of the most common preventable causes of death in infants, kids, and teens. Learn how to protect against this tragedy!

Summer is on its way. We’ll soon be visiting lakes and pools to cool off from the heat. Unfortunately drowning is the leading cause of unintentional injury-related death in children between ages 1 and 4. It continues to be a top cause of unintentional death among other age groups through the early adult years. Fortunately there are many precautions we can take to help lower the risk.

I wrote about Sun and Water Safety last summer, and want to remind everyone about the risks of drowning. I also wrote about Dry Drowning previously, but it seems that it isn’t really a thing – see the addendum in that post.

What are the risks?

About 1 in 5 people who die from drowning are children 14 and younger. Each year about 300-500 children under 5 years of age drown.

For every child who dies from drowning, another five receive emergency department care for nonfatal submersion injuries. Even though they’re not fatal, they have significant consequences.

Over half of drowning victims treated in emergency departments require hospitalization for further evaluation and treatment. These nonfatal drowning injuries can cause severe brain damage that may result in long term disabilities such as memory problems, learning disabilities, and a permanent loss of basic functioning.

What increases the risks?

Lack of Swimming Ability: Many adults and children report that they can’t swim. Swimming lessons can reduce the risk of drowning among children. See the link at the bottom for more on swim lessons.

Lack of Close Supervision: Drowning can happen quickly and quietly anywhere there is water. This includes bathtubs, swimming pools, pet water bowls, and buckets. This is why non-swimming times account for most drowning accidents.

Location: Most children 1-4 years of age drown in home swimming pools. More than half of the drownings among those 15 years and older occurred in natural water settings, such as lakes.

Failure to Wear Life Jackets: Most boating deaths are caused by drowning, with 88% of victims not wearing life jackets.

Alcohol Use: Among adolescents and adults alcohol use is involved in up to 70% of deaths associated with water recreation.

Seizure Disorders: For persons with seizure disorders, drowning is the most common cause of unintentional injury death, with the bathtub as the site of highest drowning risk.

How can you recognize drowning?

Movies show people splashing around and yelling for help as they drown.

Don’t let that fool you. Movies are not reality.

Signs of drowning:

Head low in the water, mouth at water level

Eyes glassy and empty, unable to focus

Head tilted back with mouth open

Eyes closed

Hair over forehead or eyes

Not using legs – Vertical

Hyperventilating or gasping

Trying to swim in a particular direction but not making headway

Appear to be climbing an invisible ladder

Trying to roll over on the back

Most drowning victims are silent. They don’t splash to get your attention. Watch this video from Inside Edition that captures several drowning victims:

Teach water safety

Learn how to swim and teach your children to swim as well. If your child(ren) are good swimmers, be sure to still have rules about pool use and limit pool access. Even strong swimmers can drown. See the link in the resources below for infomation on swim lessons.

No one should swim alone. If your children are not able to follow that rule, the pool should not be accessible to them. Gates and alarm systems can be used to limit access to home pools and hot tubs.

Not all teens are safe swimmers, but they don’t often fess up to their friends. They are also at risk of making impulsive decisions to drink alcohol near water, forego their life vest on a boat, jump off a cliff into water, or other things that could put them at risk. Talk to your teens about safety – in and out of the water! Encourage teens to learn CPR.

Making home water safer

All pools should have a 4 foot fence around all sides. This includes below-ground pools as well as portable pools. It is much less safe to use the house as one of the borders, since young children can escape out the door and into the pool, but if you must use your home, take precautions. Install an alarm system to alert you if the door to the pool area is opened. Use a pool or spa cover when the pool or spa is not in use.

A short word on portable pools. They can include inexpensive blow up pools and larger pools. Portable pools present a real danger to young children because they are often not seen as a threat. Portable pools account for 10% of the total drowning deaths for children younger than 15 . They should be drained, covered, or fenced to protect children. Don’t leave them in the yard unattended.

Ask neighbors to put a proper barrier around their pools or hot tubs.

Ensure any pool or hot tub (spa) you use has anti-entrapment safety drain covers.

Have life saving equipment such as life rings, floats or a reaching pole available and easily accessible.

From https://downloads.aap.org/DOPA/Drowning-Prevention/pool_safety_english.pdf

It’s not just pools that are risks…

Bowls and buckets

Keep pet water bowls out of reach of young children.

Drain any buckets of water after they’re used.

Toilet dangers

Close bathroom doors and toilet lids to keep young ones from playing in the water.

Bath time

Monitor young kids and those with seizure risks in the bath the entire time. Do not leave the room even for a few moments.

Don’t read or check your phone when you’re watching kids in the tub, just like at the pool.

Drain the bath tub before young kids even get out. This not only helps your kids not climb back in (a common reason to need stitches when kids slip trying to climb in), but it also prevents them from drowning in left over water.

It’s not just Momo… Even if she started as a hoax, we DO need to protect our kids online.

The news is full of stories about Momo and other scary things our kids are exposed to online. Many stories say this is a hoax. YouTube has said this would be against their rules. It doesn’t really matter if this started as a hoax or if it’s against the rules. The fact is that our kids are exposed to things online.

Our kids do see inappropriate things

I recently saw a preschool aged child for a well visit. During the visit it came up that the child had been exposed to Momo online. When the mother learned that the child saw scary Momo videos, she came up with a great plan. They took images of Momo and transformed her into funny faces, much like what I did for the image above.

I think this mother’s idea is great. She took a character that was scary to her child and made it funny. She used the opportunity to talk to her child. It became a great teaching moment.

Our kids can never “un-see” what they’ve seen, but we can help them to not view it as so scary. If you are unable to do this alone, talk to your pediatrician or a therapist.

When things happen we need to find ways to help our kids process them. If your child’s mood or behavior suddenly changes, it is quite possible that they have experienced a traumatic event of some sort. If they won’t talk to you, seek professional help.

What can we do to prevent online exposures?

We can’t stop all exposures, but we can do many things to help protect our kids. This includes monitoring software, anti-virus software, and teaching our kids how to behave responsibly and safely.

Increasing responsibility

Our kids will be online, whether it’s at home or at school or at a friend’s house. They are growing up with the world at their fingertips through the internet, so we must teach them to use it wisely.

Like in other benefits and responsibilities of growing up, our kids should have fewer limits and less monitoring as they show maturity. We cannot expect them to be responsible online at 18 years of age if they never practice with supervision along the way.

Give your kids age-appropriate allowances for games, videos, and other online experiences. I love to use Common Sense Media to learn about movies, games, and other media.

Set up parental controls.

Research parental control software. It’s easy to search “parental control apps” or “parental control software reviews” to find the pros and cons to various brands.

Choosing the best for your family is not easy, but read several reviews to find what is best for your family’s needs.

Adult supervision and guidance

If our kids are playing outside, they will have close supervision when they’re young, less as they get older.

Online use should be no different.

Your 3-4 year old should not go to the park alone and they shouldn’t go online alone. If they are online, project the screen to the television so you can watch along or sit with them and play along with them. They should not be online when you are busy doing something else. It is not a safe babysitter.

As kids get older and can understand how to navigate the internet more safely, they can have less and less direct supervision. This does not mean they can have a free for all. Parents can still help them choose age-appropriate sites and have software to keep blocked sites from being accessible.

You can’t just avoid online use

Several parents over the years have tried to end the conversation when I bring up social media safety by saying, “we don’t allow any of that.”

It is not sufficient to simply not allow any social media. Our kids and teens will come across it, whether it’s their own account or a friends.

What things did you do as a teen that your parent didn’t know about? It’s even easier for kids to hide social media accounts than it is for them to do many of the things we used to do as kids.

As kids grow

Have discussions about oversharing. Predators look for ways to identify where kids hang out. Kids shouldn’t give a team name or mention that their soccer game is tomorrow morning at 9. That innocent information can help a predator find them. Even photos with identifying information, like a school shirt or team jersey, can be risky if shared publicly.

Kids sometimes get tricked into sharing photos that are inappropriate. This includes pornographic images as well as snapshots identifying where to find them.

Talk about their digital footprint. Schools and employers will look at your child’s online history. It needs to be positive and what they post today will be there forever.

Teach kids basic right and wrong

We cannot protect our kids from everything, but we can teach them to be good decision makers.

Use real life examples and daily experiences to help your kids learn to make safe choices. Let them accept more responsibility and make more choices as they get older. Allow them to make the wrong choice sometimes. They’ll learn from these little mistakes much more than they would if you refuse to let them do that little mistake. This helps to prepare them to make the right choice with the riskier options as they grow.

For example, if your middle school child wants to stay up late to watch a movie but you know he has an early soccer game, discuss the situation with him. Let him make up his own mind in the end – without being judgmental. If he struggles getting out of bed and disappoints his teammates because he’s too tired, is that really the worst thing in the world? I bet the next week he won’t beg to stay up late so much. Just don’t play the “I told you so” game or give attitude about it. That will make him mad at you.

Let kids learn from their own mistakes without discussion or lecture. Kids learn from things like this if we let them. Trust me, there are lots of opportunities for them to learn to make safe, responsible choices as they grow.

In the end, if our kids want to find an inappropriate site or do something they’re not supposed to do, they will. If they use good judgement and make safe choices in other aspects of life, they are more likely to do so online too.

Be vigilant

It’s not just Momo… Even if she started as a hoax, we DO need to talk to our kids about risks online.

Follow your kids on their social sites. Talk about what sites they can and cannot use, but remember that it is easy for them to set up hidden accounts. That’s why it’s so important to talk to your kids and let them make their own choices as they grow. If you don’t allow options and never let them fail, they will not learn. The more you restrict them, the more they’ll hide from you.

Listen in as I talk about ADHD. I even throw in several stories from my own experiences in parenting a child with ADHD.

I was recently interviewed about parenting a child with ADHD. I encourage parents of kids with ADHD to listen.

As a pediatrician I have the benefit of seeing many families affected by ADHD, and that has helped me to be a better parent. It has also given me support when things don’t go well because I know I’m not alone.

If you’re feeling frustrated with parenting, especially when it’s related to those issues common to kids with ADHD, I encourage you to listen.

When your family gets sick, what can you do before running to the ER or clinic?

When cold and flu season is in full gear, it’s helpful to know common things that can help us prevent and treat whatever is in town. Many of the viruses that run around each season don’t have specific treatments, but there are things that we can do at home to treat symptoms and keep people more comfortable. There are also things we can all do to prevent the spread to other family members or back into our community.

What can be done to feel better?

Remember that nothing can be done to treat most viruses. Our body’s immune system will take care of that, but we can do things that help us feel better during the illness.

It’s hard to make them better, but we can make them feel better

During the cold and flu season, it can seem like kids are sick every day for months because they catch one on top of the other. Some of these days they might simply have a runny nose, and those days can last most of the year in young kids.

It’s when they seem uncomfortable or distressed that we need to do more. Treat the symptoms that bother them.

Identify the symptoms that are concerning, such as difficulty breathing or dehydration, and seek treatment at your doctor’s office for those.

What about fever?

Doctors don’t do anything special for fever in vaccinated children over 2 months of age.

Fever can accompany other symptoms that may be concerning, but it in itself is not the concern unless it is a newborn, unvaccinated child, or one with a chronic condition that you’ve been warned has increased risks.

Remember the goal is not to bring temperatures to normal, but to keep kids comfortable. If they’re in pain from sinus pressure, a headache, sore throat, body aches, or earaches, it is okay to give a pain reliever even with a normal temperature.

Get the mucus out

Suction your infant’s nose before feeding and before putting him down to sleep. This helps clear the mucus from the airway and makes breathing easier. Encourage nose blowing for those old enough to know how to blow.

Hydrate

Encourage your family members over 6 months of age to drink more water than normal when sick. Kids often won’t eat well when they’re sick. That’s okay. It is important that they drink well though so they can stay hydrated.

Young infants should not drink water, but you can encourage more of their milk or formula when they have cough and colds.

If your child has vomiting or diarrhea, avoid cow’s milk products. These often lead to more vomiting. Breast milk can be offered in small amounts frequently to infants who are breastfeeding. Electrolyte solutions (with sugars and salts) can be given to infants and children for hydration.

Clean air

DO NOT let anyone smoke around your child or in your home. Smoke can make the wheezing and coughing worse, even if done in a separate room in the home.

Smoke residue on hair and clothing can cause irritation to your child’s airways. I can usually identify smokers or people who spend time with smokers when they’re in my clinic. (Thankfully that isn’t often.) It isn’t unusual for me to start coughing when they’re in a clinic room with me. If you must smoke, go outside and wear a jacket that can be removed to minimize what is on your shirt when you go inside and hold your baby.

I’ve even started coughing when around someone who was vaping. I know people claim that the vapor is safe around others, but my lungs don’t like it. Keep it away from your kids. Talk to your kids about the risks of vaping so they don’t start the habit.

Rest

Encourage those who are sick to get extra rest. We often sleep poorly at night and need daytime naps to get enough sleep when we’re sick.

Dry air

A cool mist vaporizer or humidifier can help your child breathe easier. Change the water every day. Clean the machine per the manufacturer recommendations.

Infection control

It just isn’t possible to keep kids from being contagious when they have a virus. They love to touch everything and share germs, so keep them home until they’re well enough to return to normal daily activities.

Stay home!

Our health department now recommends that everyone with influenza stays home for 7 days following the start of symptoms.

You can return to work, school, and activities with other illnesses when the fever is gone (without using fever reducers) for 24 hours, there’s no vomiting or diarrhea, and you’re generally feeling well enough to return. If not, stay home and rest or visit your doctor.

Cover the cough!

Teach kids to sneeze and cough into their elbow or a tissue. Wash hands after handling tissues.

Wash, wash, wash

Good handwashing can help decrease the spread of viruses.

Wash hands often. If soap and water isn’t available, use hand sanitizer. The more things you touch, the more often you should wash.

Teach kids to wash properly. Have them rub soap on their hands for 15 – 20 seconds- be sure they scrub palms, backs of hands, fingers, spaces between the fingers and even under the fingernails.

Wash

Before preparing food

After toileting or changing a diaper

When they’re obviously soiled

Before eating

After sneezing or coughing into hands or wiping nose

Before and after touching eyes

When taking care of a wound wash your hands before and after washing and treating the wound

Often when taking care of someone who is sick

After touching trash or soiled objects

Consider having separate towels for each family member in your bathrooms to decrease the spread of germs when they wipe their mouth after brushing their teeth.

Hand sanitizer is a good option when washing isn’t available, but it is not helpful against some germs, so handwashing is preferred.

Use lotion as needed to keep your skin moisturized. Dry skin damages the barrier that helps prevent germs from getting into our bodies.

Germs can live on objects and surfaces for 2 or 3 hours – sometimes longer. Clean your child’s toys often with soap and water.